What Does Breaking Your Waters Actually Involve?

Firstly, before anything else - you should have made an informed choice and given your consent for a vaginal examination to occur and to have your waters broken. You should not have, for example, agreed to the vaginal examination and then be asked mid-examination if you want your waters broken. That’s not informed consent. You need time to weigh up the pros and cons of having your waters broken and that cannot be done if someone is mid-examination, with their fingers inside of you.

On to the practical stuff. For your waters to be broken, you’ll be asked to get into position for a vaginal examination. This means lying on your back, supported by pillows, underwear off, ankles up close to your bottom and knees wide open. You’ll usually be lying on top of an absorbent bed pad and should be offered a cover. If you’re not having CTG monitoring, the midwife should offer to check your baby’s heartbeat with a handheld doppler or a pinard before and after doing the examination.

The midwife or doctor should wear sterile gloves, they’ll apply some lubrication and then insert two fingers into your vagina, with your explicit consent. Once they have located your cervix and assessed if they can break your waters (ie. if your cervix is open enough and they can reach it), they’ll use something that’s called an ‘amnihook’ and looks a bit like a long flattened crochet hook. They’re single use, made of plastic and have a little sharpened point at one end. The amnihook is inserted into your vagina carefully to avoid scratching you with the hook. When the bag of water around your baby can be felt, the hook will then be used to break them. The midwife or doctor will then most likely gently remove the amnihook and assess your cervix to see if there is any difference once the waters have gone. Sometimes a bulging bag of waters can stretch the cervix so the examination findings might be different pre and post waters breaking. You should then be told what the findings are - this includes those of your cervix, the position of your baby in your pelvis and also the colour of your waters if you haven’t seen them already. Waters can be a variety of colours: clear, pinkish, brownish, green - the last two generally mean there’s meconium present aka your baby has done a poo inside. Meconium doesn’t automatically equal a problem - we’d highly recommend reading Rachel Reed’s article all about it to get some perspective.

You’ll probably find you’ll leak water until your baby is born, so you may choose to wear pants and a pad. How much water comes out at the point of your waters being broken varies from person to person - for some it’s a big gush, and others more like a trickle.

What Does It Mean When Labour Is "Slow"?

How Slow Labour Is Diagnosed

According to UK NICE guidelines, cervical dilation of less than 2cm in 4 hours should be considered a delay in labour. In this instance the advice from NICE is to offer a vaginal examination 2 hours later and if the cervix has dilated less than 1cm in that time, to diagnose a delay in the first stage of labour. The guidelines go on to recommend that clinicians consider breaking the waters (if they’re intact) in this scenario.

Alternatives to Vaginal Examinations for Checking Progress

It’s routine practice to offer all women 4 hourly vaginal examinations in labour and the diagnosis of a delay in labour relies on vaginal examinations. It’s worth noting that routine vaginal examinations in labour haven’t been shown to improve outcomes for women and babies. Vaginal examinations can be a useful clinical tool and they make more sense where labour is being induced because you want to know that the induction is working or if you have an epidural and can’t feel as much - but even then, there’s been no research to say what the optimal time between vaginal examinations is in these scenarios.

Routine examinations can be disruptive particularly in a physiological, unmedicated labour and birth - they can disrupt your flow, be uncomfortable and painful and perhaps be discouraging if your cervical dilation is less than expected. An examination only tells you what’s going on at that point in time - it cannot predict when your baby will be born.

However, there are many other ways of assessing if someone is progressing in labour, but these largely apply to people who have not got epidurals on board. Epidurals change how you behave in labour and what you can feel.

Some of the ways that we know that your labour is progressing include:

• Changes to your behaviour and movements
• You might become more vocal
• You telling us you can feel your baby moving down
• Presence of a Rhombus of Michaelis
• Presence of a purple or silver line between your buttocks
• Observing the strength and frequency of your contractions

Why Cervical Dilation Doesn't Follow a Fixed Timeline

It’s foolish to assume that all women and birthing people would dilate at exactly the same, linear rate. Every midwife will have a story of a woman who was ‘only 2cm an hour ago’ who then promptly gives birth to a baby. Some people dilate slower or faster than others and neither of these things is necessarily a problem - research supports this. Labour is about so much more than just your cervix. How your baby navigates your pelvis and their position during labour might affect how your cervix opens, for example it’s not uncommon in practice where a baby is back-to-back for a cervix to dilate ‘slowly’ or seem to stall before suddenly opening all the way quickly once the baby has rotated to a different position.

What the Evidence Says: Breaking Waters and Caesarean Risk

The 2013 Cochrane review looking at amniotomy in spontaneous labour (i.e. not induced labour!) concluded that ‘the evidence showed no shortening of the length of the first stage of labour and a possible increase in caesarean section’. This review looked at 15 studies, involving 5583 women. The Cochrane review found trend towards caesarean birth in women who had had their waters broken - but they couldn’t definitely say that having your waters broken increased your risk of caesarean birth as there were confounding factors, such as CTG monitoring - which is known to increase the chance of caesarean birth. More research is needed…as usual!

The Risks and Benefits of Breaking Your Waters in Labour

The risks associated with breaking your waters include:

• Possibly more painful contractions after waters have broken
• Bleeding, pain and discomfort from the vaginal examination
• Possible increased risk of fetal distress due the equalising pressure of the waters being lost
• Slight increased risk of infection
• Cord prolapse (This is rare, but means where a section of the umbilical cord slips past the baby’s head, through the cervix and into your vagina - it’s an obstetric emergency and usually you’ll be rushed to theatre for an emergency caesarean birth)

NICE guidelines include that a potential benefit of having your waters broken is that it will shorten labour by about an hour…which may or may not feel significant to you in the grand scheme of things and needs to be weighed up against the potential risk factors. It also contradicts the Cochrane review findings…

Rachel Reed wrote a brilliant article on the topic of keeping waters intact - read it here for more information.

Your Right to Informed Consent During Labour

None of the above is a reason to never have your waters broken - it's a reason to make sure the decision is actually yours. Informed consent is an ongoing conversation and in practice, that means you should be given:

• The reason why breaking your waters is being suggested at this particular point - not just ‘it's what we do’, but the specific clinical picture that's prompted the offer.
• The evidence, including the uncertainty - the honest version, which is that it may shave an hour off labour but hasn't been shown to reduce caesarean rates and may even nudge them upward
• The alternatives, such as waiting, trying position changes and movement, or having another examination later rather than intervening now
• The risks, spelled out plainly rather than glossed over
• Time and space to decide, without fingers already inside you and without being made to feel like ‘difficult’ for asking questions

You’re allowed to say: yes, no, or not yet. You can ask what happens if you decline - the BRAINS decision making tool can come in handy to help make your decision. A slower labour is information, not generally an emergency situation. You have time to make the decisions that feel right for you and should be supported to do so by your midwife.

Watchful Waiting: Our Approach to Midwifery Care

If we suspect that your labour has slowed down, we're unlikely to jump straight to offering to break your waters and that’s because labour slowing down does not always mean there’s a problem. Sometimes labours plateau and there’s a rest period, which is kind of genius really. What it can look like in practice is contractions fading, spacing out, shortening or becoming irregular where before they were doing the opposite.

In the absence of any clinical concerns, our starting point is watchful waiting - giving your body, and your baby, a bit more time before reaching for an intervention. That might mean:

• Encouraging movement, upright positions and position changes rather than suggesting a vaginal examination straight away
• Supporting you to eat, drink and rest - labour is hard work. Being dehydrated for example can affect how the muscles of your uterus function
• Creating the conditions oxytocin needs to flow - dim lighting, privacy, quiet, feeling safe and unobserved
• Looking at the whole picture - your wellbeing, your baby's wellbeing, your energy and demeanour, the signs listed above - rather than relying on dilation in centimetres as the only measure of progress
• Talking with you about what you're feeling and what you want, before we talk about what we could do

None of this means we ignore signs of a problem. If we have concerns about you or your baby’s wellbeing, we’ll be transparent about that and make a clinical recommendation. We’ll listen if you tell us you have concerns about yourself or your baby. In these scenarios, and where labour truly isn't moving despite time and support, we’ll be honest with you - breaking your waters at home is unlikely to be our suggestion. We would most likely recommend transfer to hospital (with us by your side, ready to advocate for you if you need it!).

A slower labour isn't automatically a problem to be fixed. Most of the time, the most powerful thing we can offer isn't an amnihook - it's patience, reassurance, and the space for your labour to unfold at its own pace.